Objectives

To evaluate the effectiveness of interventions which aim to encourage women to breastfeed in terms of changes in the number of women who start to breastfeed.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2007), handsearched the Journal of Human Lactation, Health Promotion International and Health Education Quarterly from inception to 15 August 2007, and scanned reference lists of all articles obtained.

Selection criteria

Randomised controlled trials, with or without blinding, of any breastfeeding promotion intervention in any population group except women and infants with a specific health problem.

Data collection and analysis

One review author independently extracted data and assessed trial quality, checked by a second author. We contacted investigators to obtain missing information.

Main results

Eleven trials were included. Statistical analyses were conducted on data from eight trials (1553 women). Five studies (582 women) on low incomes in the USA with typically low breastfeeding rates showed breastfeeding education had a significant effect on increasing initiation rates compared to standard care (risk ratio (RR) 1.57, 95% confidence interval (CI) 1.15 to 2.15, P = 0.005). Subgroup analyses showed that one-to-one, needs-based, informal repeat education sessions and generic, formal antenatal education sessions are effective in terms of an increase in breastfeeding rates among women on low incomes regardless of ethnicity and feeding intention. Needs-based, informal peer support in the antenatal and postnatal periods was also shown to be effective in one study conducted among Latina women who were considering breastfeeding in the USA (RR 4.02, 95% CI 2.63 to 6.14, P < 0.00001).

Authors' conclusions

This review showed that health education and peer support interventions can result in some improvements in the number of women beginning to breastfeed. Findings from these studies suggest that larger increases are likely to result from needs-based, informal repeat education sessions than more generic, formal antenatal sessions. These findings are based only on studies conducted in the USA, among women on low incomes with varied ethnicity and feeding intention, and this raises some questions regarding generalisability to other settings.

Plain language summary

Interventions for encouraging women to start breastfeeding

The World Health Organization recommends that all infants should be fed exclusively on breast milk from birth to six months of age. Breastfeeding is supported by extensive evidence for short-term and long-term health benefits, for both mother and baby. Babies who are not fully breastfed for the first three to four months are more likely to suffer health problems such as gastroenteritis, respiratory and ear infections, urinary tract infections, allergies and diabetes mellitus. Practical benefits include savings on buying artificial formulas, particularly where they are not subsidised. Yet many women choose to bottle feed their babies. Reasons include personal and social biases against breastfeeding such as attitudes of family and close friends, attitudes to breastfeeding in public and employment practices.

This review showed that health education and peer support interventions can result in some improvements in the number of women beginning to breastfeed. Studies were of low-income women in the USA, where baseline breastfeeding rates are typically low.

Eleven randomised controlled trials were included. Eight trials involving 1553 women contributed to the data. Five studies with 582 women on low incomes in the USA showed breastfeeding education clearly increased breastfeeding rates compared to providing routine care. One trial with 165 women showed peer support for women considering breastfeeding also increased breastfeeding rates. Needs-based, one-to-one, informal education or support sessions, delivered either before or before and after the birth by a trained breastfeeding professional or peer counsellor, was the most effective intervention among women of different ethnicity and feeding intention in three studies. The one evaluation of hospital breastfeeding promotion packs compared to formula-company produced materials about infant feeding showed this intervention to be ineffective. Approximately 40% of women in both groups reported receipt of formula company promotion items from sources other than their obstetric provider.

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Background

This review aims to assess ways of promoting breastfeeding. Fewer resources have been spent on this than on the promotion of formula feeding. Women in most countries encounter promotion of formula feeding in various forms, a factor which has been implicated in women choosing to feed their babies on formula (WHO Data Bank 1996).

Other social and practical benefits to the breastfeeding mother include the increased likelihood she will use up the body fat deposited in pregnancy (Dewey 1993; Kramer 2002), substantive savings on the expenses associated with formula feeding (except in the case of mothers participating in welfare schemes and receiving subsidised formula milk powder), and the avoidance of effort and risks involved in preparing formula feeds (MIDIRS 1997; Bryant 1990).

Attempts have been made to quantify public cost benefits of breastfeeding. Recent National Institute for Health and Clinical Excellence (NICE), guidance on modelling the cost effectiveness of breastfeeding to the UK National Health Service (NHS) estimates that peer support which achieves an estimated 20 percentage point increase in breastfeeding initiation would save the NHS money over the long term (NICE 2007). The model suggests that such a scheme would avert 2.7 per 10,000 cases of pre-menopausal breast cancer in mothers and 285 per 10,000 cases of infections requiring hospitalisation in the first year of life. At the current NICE threshold for cost per quality-adjusted life year (QALY) gained (£20,000-£30,000), it estimates that expenditure on breastfeeding support would be justified in competition with other demands on NHS resources by an increase in initiation rates of about 15 percentage points. The authors note that evidence on other potential health benefits and savings, such as improved health of breastfed babies later in life and reduced spending on infant formula, is too complex to be accounted for by the model. Results will therefore tend to underestimate the cost-effectiveness of peer support interventions. The authors found the quality of evidence concerning the efficacy and cost of public health interventions designed to promote breastfeeding to be poor.

Despite the documented risks of formula feeding, many women choose to formula feed their babies. Given the wide variations in rates between countries and population groups (see below), the reasons for this are likely to be socio-cultural and include personal, social and structural biases against breastfeeding. These may include attitudes of family and close friends, attitudes to breastfeeding in public and employment practices (Renfrew 1998). The availability of subsidised infant formula milk through welfare food programmes, such as the UK based Healthy Start Scheme and the USA based Women, Infant and Children Supplemental Feeding Program, may be an economic factor which contributes unintentionally to women in low-income groups deciding to formula feed. The extent to which individual countries have adopted the World Health Organisation's International Code of Marketing of Breast Milk Substitutes (WHO 1981) may also be a contributing factor to the infant feeding decision, particularly for women in low- and middle-income countries. The WHO Code (WHO 1981) was adopted by the World Health Assembly in 1981 and is currently supported by over 20 countries with draft laws awaiting adoption in others. Increased support to adopt the WHO/UNICEF Code (WHO 1981) into national legislation would prohibit the provision and promotion of breast milk substitutes to pregnant women, new mothers or families.

International rates of initiation of breastfeeding are extremely variable between and within countries (seeAppendix 1). Historically, breastfeeding rates have been high in many resource poor-countries despite variation in urban and rural areas. In Scandinavia and Eastern Europe, many countries have a high incidence of women starting to breastfeed. Other individual countries with breastfeeding initiation rates of over 90% include Japan, Switzerland, Luxembourg and Turkey. In central and southern Europe, initiation rates remain relatively high at around 70% to 80%, for example, in Italy, Spain and Greece.

North America and much of Western Europe have experienced lower rates of initiation of breastfeeding since the early 20th century. Significant increases have been experienced in some countries over the last decade. For example, recent UK data show that 78% of mothers initiate breastfeeding in England, 70% in Scotland, 67% in Wales and 63% in Northern Ireland (Bolling 2007) (seeAppendix 2); and 85% and 74% of mothers start to breastfeed in Canada (Millar 2005) and the US (CDC 2004) respectively.

In all countries, breastfeeding initiation rates are closely related to social class, income and educational levels. In those high-income countries where breastfeeding rates are typically low, the lowest rates are found among women in low-income groups. In England and Wales, for example, only 65% of women classified as having 'never worked' or 65% of women in 'lower occupations' initiated breastfeeding in 2000 compared to 88% of women classified in 'higher occupations' (Bolling 2007). It is therefore important to examine which interventions might have an impact on rates in these groups.

The purpose of this review is to examine interventions which aim to encourage women to breastfeed, to evaluate their effectiveness in terms of changes in the number of women who initiate breastfeeding and to report any other effects (beneficial or adverse) of such interventions.

Objectives

To identify and describe health promotion activity intended to increase the rate of initiation of breastfeeding.

To evaluate the effectiveness of different types of health promotion activity, in terms of changing the number of women who initiate breastfeeding.

To compare the effectiveness of different types of health promotion interventions as appropriate.

To assess the impact of these interventions on secondary outcomes, namely, duration of any or exclusive breastfeeding and any adverse outcomes as a result of the intervention.

Methods

Criteria for considering studies for this review

Types of studies

Randomised controlled trials, with or without blinding. There was no limitation of study by country of origin or language.

Types of participants

All those exposed to interventions intended to promote breastfeeding. This includes pregnant women, mothers of newborn infants and women who may decide to breastfeed in the future. We also included population subgroups of women, such as women from low-income or ethnic groups. Women and infants with a specific health problem, e.g. mothers with HIV/AIDS or infants with cleft palate, or premature babies, are excluded from this review.

Types of interventions

Any intervention aiming to promote the initiation of breastfeeding, which takes place before the first breastfeed. Evaluations of interventions taking place after the first breastfeed or whose primary purpose is to affect the duration or exclusivity of breastfeeding are excluded from this review.

Details of the search strategies for CENTRAL and MEDLINE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the ‘Specialized Register’ section within the editorial information about the Cochrane Pregnancy and Childbirth Group.

Trials identified through the searching activities described above are each assigned to a review topic (or topics). The Trials Search Co-ordinator searches the register for each review using the topic list rather than keywords.

Further details of searching carried out for the initial version of this review can be found in Appendix 3.

Searching other resources

We handsearched the Journal of Human Lactation, Health Promotion International and Health Education Quarterly from inception to August 2007.

We scanned reference lists of all relevant papers retrieved.

We did not apply any language restrictions.

Data collection and analysis

Two authors independently assessed over 1400 titles and abstracts of studies, identified from all sources, for relevance. Where no clear decision could be made on the basis of the title or abstract, we considered the studies relevant. This process identified 83 potentially relevant studies for which we retrieved full reports for more detailed consideration.

One author used a prescreen form to systematically assess retrieved papers against the inclusion criteria and to classify included studies by the type of health promotion intervention. This included three papers which required translation into English before prescreening, namely, papers in Portuguese, Russian and Croatian. We contacted authors to clarify or obtain relevant details of individual studies, particularly to request details of their randomisation processes. A second author independently checked fifty papers that were classified as possible exclusions during the prescreening process. We excluded all. Two studies we previously identified as ongoing have been completed but not yet published and are awaiting assessment for this review.

One author used data extraction and quality appraisal forms to extract data from the remaining eleven studies. A second author then checked the data. Any disagreements were settled through discussion between authors. This resulted in eleven studies being included in this review, eight of which contributed data to the meta-analyses. Studies were classified by type of intervention: health education of pregnant women, health education of significant others of pregnant women, peer support, health education of pregnant women and peer support, breastfeeding promotion packs, and early mother-infant contact. One author entered data into the Review Manager software (Revman 2008).

We assessed the validity of each included study according to the criteria outlined in the Cochrane Handbook (Higgins 2008). We assessed selection bias on the basis of concealment of allocation: adequate; unclear; or inadequate. We rated performance bias, attrition bias and detection bias as: adequate; unclear or partially adequate; or inadequate.

For eight studies, we considered meta-analysis appropriate to evaluate the effect of each type of intervention which measured the primary outcome of initiation of breastfeeding. The reasons for not including data from three studies (Caulfield 1998; Forster 2004; Wolfberg 2004) in the meta-analyses are given in Description of studies. Figures show calculated individual and pooled risk ratios with 95% confidence intervals for dichotomous data on initiation of breastfeeding from studies where data allow an estimation. We calculated the individual risk ratios on an intention-to-treat basis where the data from primary studies allow participants to be analysed according to the group to which they were initially allocated, regardless of whether or not they later withdrew or were lost to the study. Key differences in characteristics of participants or methods of implementation of the intervention, or both, are discussed in the interpretation of results (see Results).

We undertook subgroup analysis to compare the differential effect of interventions on initiation rates for studies within the education and education or peer support categories. This was possible due to the similarities between subgroups of interventions and low levels of statistical heterogeneity .

The nature of health promotion interventions to achieve a positive outcome in terms of an increase in the number of women starting to breastfeed warrants reversal of the traditional Cochrane Database of Systematic Reviews convention whereby a risk ratio of less than one indicates that the intervention is better than the control (Alderson 2004). For the purposes of this review therefore, a risk ratio of more than one indicates that the intervention has a more favourable effect on initiation rates than the control. This is displayed by the dot appearing to the right of the central vertical line that indicates no difference.

To summarise results, we began by using a fixed-effect approach. This approach assumes differences among study results are due solely to the play of chance (Higgins 2006). If the forest plot showed substantial statistical heterogeneity (I2 > 50%) using a fixed-effect approach, we then re-analysed the study results using a random-effects model to estimate the average treatment effect (Higgins 2006).

No studies measuring the primary outcome of initiation rates of breastfeeding were excluded from the review and no sorting of studies for ordering of meta-analyses was considered necessary on the basis of methodological quality. Three studies included in the review did not contribute data to the meta-analyses, as detailed below.

Caulfield 1998 randomised four WIC clinics in one US city. One clinic received no intervention, one received a breastfeeding motivational video, another received a peer counselling intervention, and the fourth clinic received both the video and peer counselling interventions. The clinic populations were 90% to 96% African-American, with breastfeeding rates of 2% to 6% at one month. Outcome data are presented for 242/674 potentially eligible women (36%) for whom complete data were available. Among these 242 women, the overall breastfeeding initiation rate (defined as ever putting the infant to the breast) was 48%. In the control clinic (n = 57) 26% initiated breastfeeding; in the video clinic (n = 64) the rate was 50%; in the peer counsellor clinic (n = 55) it was 62%; and in the clinic that used both the interventions (n = 66) the breastfeeding initiation rate was 52%. We sought statistician's advice about whether we should include this study as a cluster-randomised trial. We were advised against inclusion because with only one clinic in each treatment group, it is not possible to calculate the standard error of difference. The paper reports that although clinic-level data had suggested the four clinics were comparable, characteristics of women who enrolled in the study were noted to vary by clinic. Therefore, although it appears that either intervention was better than none for promoting breastfeeding initiation, it is not possible to estimate their effects with any precision.

Forster 2004 reported a randomised controlled trial that took place in Melbourne, Australia, in a hospital that had been Baby-Friendly accredited for four years before the trial began. Women booking to have their first infant at the hospital were eligible if they were public patients, 16 to 24 weeks' pregnant at recruitment, and able to speak and write in English. In addition to Baby-Friendly standard care (n = 327), there were two interventions; practical skills (n = 327) and attitudes (n = 327) (details of the interventions appear in the Characteristics of included studies table). Breastfeeding initiation rates were high in all three groups (97% for the practical skills intervention, 95% for the attitudes intervention, and 96% for Baby-Friendly standard care). The researchers conclude that in settings where breastfeeding initiation is high, neither of the two interventions can be recommended as effective. Results from this large, well-reported trial are not included in the meta-analyses for this review. We considered the control group who received standard care compliant with the Baby-Friendly initiative had in effect received a third intervention that meant we could not compare this control group with the control groups of other studies in the review.

Wolfberg 2004 reported a randomised controlled trial with expectant fathers who were partners of women seeking prenatal care at one US hospital. Participants were predominantly black women receiving benefits under the federal Women and Infants Supplementary Feeding Program. The intervention group attended a two-hour class on infant care and breastfeeding promotion, and the control group attended a class on infant care only. Both classes were facilitated by the same person, a black father who was knowledgeable and used a non-didactic and informal method of education. Women whose partners attended the intervention class had a 74% breastfeeding initiation rate (20/27) compared with 41% (13/32) whose partners attended the control class. The authors reported significant attrition. They approached 567 pregnant women and reported data from 57 couples (10%). The numbers randomised to each group are not reported therefore results from this trial have not been included in the analyses for this review.

Among the excluded studies are four studies which were excluded due to lack of information about outcome data or method of randomisation despite efforts to contact the authors (Chapman 1986; Grossman 1988; Mattar 2007; Winterburn 2003), and one study which is ongoing but would not be included on completion due to the aims of the study being outside the focus of this review (Chong 2007). Two studies are awaiting assessment (Hoddinott 2007; Wambach 2006).

(3) Breastfeeding promotion packs - one trial

(4) Early mother-infant contact - one trial

Lindenberg 1990: hospital based early mother-infant contact combined with minimal breastfeeding education intervention delivered to primiparous women living in poor urban areas of Managua with a mean age of 20 years.

No trials of population-based programs to promote initiation of breastfeeding were found.

Given that there are genuine pragmatic considerations when delivering and evaluating breastfeeding promotion interventions, the ability to reduce performance bias is limited and this should be recognised as an inherent weakness of this particular type of evidence base rather than of the particular studies included in this review. The only study which was considered to have adequately addressed potential sources of performance bias was the evaluation of a breastfeeding promotion pack compared to a commercial formula pack (Howard 2000), which was able to maintain blinding of both participants and providers through the use of sealed, similarly designed, packs more comparable with the use of a placebo and treatment in a therapeutic trial.

In the case of detection bias, the objective nature of the outcome being assessed, namely, whether a woman starts to breastfeed or not at a predefined timepoint, limits the scope for potential influence by the assessor, regardless of their being blind to the participant's group allocation.

(1) Health education interventions (comparison one)

Five studies (Brent 1995; Coombs 1998; Hill 1987; Ryser 2004; Serwint 1996) (including 582 women) evaluated the effect of health education on the initiation of breastfeeding. When all studies were combined for meta-analysis, a statistically significant increase in the number of women starting to breastfeed was demonstrated as a result of the health education interventions (risk ratio (RR) 1.57, 95% confidence interval (CI) 1.15 to 2.15). These interventions were all conducted among women on low incomes in one high-income country setting (USA). Substantial statistical heterogeneity between the six studies included in this analysis is suggested by the heterogeneity score above 50% (I2 = 53.4%).

Subgroup analysis of two studies (Brent 1995; Ryser 2004; including 162 women) evaluating the effect of repeat, informal breastfeeding education which was personalised to each woman's needs demonstrated a statistically significant increase in the number of women starting to breastfeed as a result of the intervention (RR 2.40, 95% CI 1.57 to 3.66). Statistical heterogeneity between these studies was small (I2 = 7.0%).

Both studies were conducted in the USA among women on low incomes from a range of ethnic groups. One intervention comprised repeat prenatal education sessions, daily perinatal input and repeat postnatal support on breastfeeding issues from a lactation counsellor based on the woman's needs and interests (Brent 1995). The other intervention comprised repeat prenatal education sessions from a breastfeeding researcher on breastfeeding issues based on the woman's concerns (Ryser 2004). Professional education was also directed at nursing and medical staff who interacted with the breastfeeding mother-infant pair. The Brent 1995 study included women regardless of feeding intention whereas the Ryser 2004 study included women who intended to formula feed or had not yet decided. Both education interventions were delivered by a breastfeeding professional or 'expert', namely, a lactation counsellor (Brent 1995) or a breastfeeding researcher (Ryser 2004).

The type of routine care received by the control group has not been specified by Ryser 2004 although care was similar between the comparison groups except for the intervention component provided to the experimental group. Brent describes routine care as optional prenatal breastfeeding classes, postpartum instruction by nurses and doctors and outpatient follow-up in the paediatric ambulatory department (Brent 1995).

The education intervention implemented in the prenatal period only (Ryser 2004) aimed to increase initiation rates and measured changes in breastfeeding at one week postpartum. The intervention which was implemented across the prenatal, perinatal and postnatal periods aimed to increase both the initiation and duration rates (Brent 1995). This study reported a significant increase in the median duration of breastfeeding as a result of this intervention (intervention: 84 days; control: 33 days).

Subgroup analysis of three studies, including 420 women, (Coombs 1998; Hill 1987; Serwint 1996) evaluating the effect of generic, formal, single breastfeeding education sessions on the initiation of breastfeeding found a positive, but non-statistically significant increase in the number of women starting to breastfeed as a result of this type of health education intervention RR 1.26, 95% CI 1.00 to 1.60). Statistical heterogeneity was not found between these studies (I2 = 0%).

One intervention comprised generic information on parenting, including the advantages of breastfeeding, to each woman during a prenatal visit in her third trimester (Serwint 1996). Routine care was described as similar except no prenatal visit was provided. The study by Hill (Hill 1987) evaluated a one-off, generic lecture and discussion about breastfeeding with a post-test questionnaire to assess change in knowledge. Routine care comprised optional breastfeeding classes and postnatal support for mothers who wish to breastfeed (Hill 1987). A generic self-help manual was provided to each woman seven weeks before her expected date of birth during a routine prenatal breastfeeding counselling session from a nutritionist (Coombs 1998). Women in both comparison groups received a total of two prenatal interviews and two postnatal interviews.

Some caution is required in interpretation of these findings due to variation between studies; for example, definitions of routine care, the methods, content and duration of the health education interventions. However, all studies were conducted among low-income women in the USA with a range of ethnic backgrounds and feeding intentions and the type of formal, generic, one-off education session was consistent across all three studies.

(2) Peer support for women considering breastfeeding (comparison two)

A single study evaluating the effect of prenatal, perinatal and postnatal peer support services among a total of 165 participants (Chapman 2004) was shown to be effective at increasing initiation rates among predominantly Latina women who were considering breastfeeding in the USA (RR 4.02, 95% CI 2.63 to 6.14, P<0.00001). Authors describe many of the study population as feeling socially uncomfortable with breastfeeding in the USA. The personalised, problem-solving approach of the intervention had been developed for 10 years in collaboration with the study hospital.

Peer counsellors were community women who have completed high school, breastfed for six months and received 30 hours of internationally recognised classroom training in breastfeeding management. Counsellors served as observers for three to six months with experienced peer counsellors, received a payment (US$12) and the potential for health benefits if working at least 20 hours per week. Counselling services included at least one prenatal home visit, daily postpartum visits during hospitalisation and at least three home visits following return from hospital.

Routine care was patient-led comprising breastfeeding information in response to participant's questions and written materials available at the prenatal clinic. Perinatal care included hands-on assistance and education from maternity ward nurses. Written breastfeeding materials and access to a Lactation Consultant for breastfeeding problems were also available if requested as was a 'warm line' where nurses answer postpartum breastfeeding questions.

A significant increase in duration rates of breastfeeding was not demonstrated at one or three months postpartum. Failure to adhere to protocol, particularly the delivery of half of postnatal home visits in the first month, was a study limitation due to staffing problems.

(3) Breastfeeding promotion packs (comparison three)

A single study (Howard 2000) involving 547 women reported on the outcome of initiation of breastfeeding. The provision of a non-commercial breastfeeding promotion pack compared to a formula company produced pack has been shown to have no effect (RR 0.93, 95% CI 0.80 to 1.08, P=0.34) on increasing initiation rates among women of middle- or higher-income groups in a high-income country setting (USA).The authors also reported no effect on rates of stopping breastfeeding up to two weeks (RR 1.58, 95% CI 0.97 to 2.56).

(4) Early mother-infant contact followed by separation (comparison four)

A single study (Lindenberg 1990) (including 259 women and their babies) reported on the outcome of initiation of breastfeeding. It must be noted that whilst this intervention evaluated early mother-infant contact immediately after birth, women and their babies were then separated for the rest of their stay. This minimal contact intervention was shown to have no effect (RR 1.05, 95% CI 0.94 to 1.17, P = 0.39) on increasing initiation rates among women living in poor urban areas in Nicaragua.

Discussion

The meta-analysis of the five studies evaluating the effectiveness of health education interventions for increasing initiation rates of breastfeeding showed the interventions were effective overall (risk ratio (RR) 1.57, 95% confidence interval (CI) 1.15 to 2.15). The studies were small, with the largest having 200 participants. All five evaluated programmes were delivered in the USA to low-income women with a range of feeding intentions and where baseline breastfeeding rates are typically low. Programme components varied; however, all forms of health education included in this review seem to have increased breastfeeding rates.

Subgroup analyses of different types of health education intervention showed that both one-to-one, needs-based, informal repeat sessions and generic, formal antenatal sessions favour the intervention in terms of an increase in breastfeeding rates among women on low incomes regardless of ethnicity and feeding intention. Findings from these studies do suggest however that larger increases in the numbers of women are likely to result from needs-based, informal repeat education sessions than more generic, formal antenatal sessions. These findings are based only on studies conducted in the USA, however, raising some questions regarding generalisability to other settings.

The single study evaluating needs-based, informal peer support in the antenatal and perinatal periods was shown to be effective at increasing initiation rates among predominantly Latina women who were considering breastfeeding in the USA (RR 4.02, 95% CI 2.63 to 6.14). These findings are consistent with those reported above for needs-based, informal health education sessions from a health professional.

The evaluation of hospital breastfeeding promotion packs compared to formula-company produced materials about infant feeding (Howard 2000) showed this intervention to be ineffective at increasing initiation rates of breastfeeding. This trial was of high quality with sample size sufficient to provide 80% power to detect a 15% difference in breastfeeding initiation between the groups. However, approximately 40% of women in both groups reported receipt of formula company promotion items from sources other than their obstetric provider. These findings suggest that this form of breastfeeding promotion intervention is not the most effective use of breastfeeding promotion resources in a context of widespread use of formula company promotion items. Future research to evaluate the effect of full implementation of the WHO Code (WHO 1981) and the use of breastfeeding promotion packs in an environment free of formula-company produced materials would provide a useful contribution to the evidence base for the promotion of breastfeeding.

The evaluation of early mother-infant contact immediately after birth prior to complete separation until discharge on breastfeeding initiation rates (Lindenberg 1990), which was the only study included in this review that was conducted in a low- to middle-income country setting (Nicaragua), found no effect. In this study the overall breastfeeding initiation rate was 87%, higher than in the other included studies. Standard care was complete separation of mother and infant throughout hospitalisation (normally 12 to 24 hours). No sample-size calculation is reported. This finding suggests that early mother-infant contact followed by complete separation did not increase or decrease breastfeeding initiation rates in a population of women with relatively high breastfeeding rates and living in poor urban areas in a low- to middle-income country. Generalisation of the result of this evaluation is not recommended due to the moderate quality and size of the study and to fundamental concerns regarding the practice of routine separation of mother and infant prior to hospital discharge. The World Health Organisation recommends mothers and infants should not be separated after birth unless there is an unavoidable medical reason (WHO 1998). In addition, the literature on the promotion of the duration of breastfeeding provides clear evidence of the benefits of ongoing mother and infant contact during the hospital stay to support the mother's ability to breastfeed (Bonnin 1989; Inch 1989; Perez-Escamilla 1994; Renfrew 2000).

The Australian study (Forster 2004) conducted in a hospital which had been accredited with Baby Friendly status (WHO 1998) for four years prior to trial implementation was also conducted among a population with high breastfeeding rates (96% for control group receiving routine Baby Friendly Initiative care). Whilst the authors of this good quality study conclude that the high breastfeeding rates may have been a factor affecting the lack of effectiveness of the education interventions (Forster 2004), the 'intervention' of Baby Friendly Initiative implemented in this hospital as routine care is also noteworthy. In the absence of a formal trial evaluating the effectiveness of the Baby Friendly Initiative intervention in this hospital or hospital baseline data on breastfeeding initiation rates prior to implementation of Baby Friendly Initiative, it is not possible to attribute the current high breastfeeding rates across the study population to the Baby Friendly Initiative (Forster 2004). Other good quality non-randomised evidence on the effectiveness of the Baby Friendly Initiative does, however, demonstrate significant increases in initiation rates among all women attending maternity services with the Baby Friendly Initiative Full Accreditation Award (Bartington 2005; Kramer 2001; Philipp 2001; Radford 2001; Tappin 2001). Indeed, the routine implementation of the UNICEF Baby Friendly Initiative to full accreditation level, or an externally evaluated structured programme using the Baby Friendly Initiative as a minimum standard, has been recommended as clinical guidance and effective action for UK maternity and community services by the National Centre for Health and Clinical Excellence (Demott 2006; Dyson 2006). This is consistent with UNICEF/WHO adoption of the Baby Friendly Hospital Initiative as a global programme to support successful breastfeeding for all mothers and babies (WHO/UNICEF 1989).

Authors' conclusions

Implications for practice

Health education and peer support interventions included in this review are likely to result in some improvements in initiation rates among low-income women in the USA where baseline breastfeeding rates are typically low. The small number of trials and participants, all of which were conducted in the USA, warrant caution for generalisability of findings to other country settings, particularly those where breastfeeding rates are typically high.

The type of education or support intervention which may be most likely to increase initiation rates among low-income women appears to be needs-based, one-to-one, informal sessions delivered in the antenatal or antenatal or perinatal period by a trained breastfeeding professional or peer counsellor. As above, generalisability of findings into practice to settings other than the USA warrants some caution.

Early mother-infant contact followed by complete separation until hospital discharge was not effective when targeting women with high breastfeeding rates living in poor urban areas in a low- and middle-income country setting. Enabling mothers and infants to remain together for 24 hours a day, 'rooming-in', is one of the Ten Steps of the UNICEF/WHO Baby Friendly Hospital Initiative adopted as a global programme to support successful breastfeeding and demonstrated to increase initiation rates for all women in all settings.

Breastfeeding promotion packs, in contexts where formula feeding packs are widely distributed, may be an inappropriate use of valuable breastfeeding promotion resources that could be more effectively used for population-appropriate breastfeeding education. However, increased support to adopt the WHO/UNICEF Code (WHO 1981) into national legislation would prohibit the provision and promotion of breastmilk substitutes to pregnant women, new mothers or families, potentially increasing the impact of breastfeeding promotion.

Implications for research

The effectiveness of interventions reviewed here needs to be assessed in diverse countries and settings, particularly outside the USA, in studies that are adequately powered, have adequate methods of randomisation, adequate reporting of losses to follow-up and utilise intention-to-treat analysis.

Publication of evaluations of effectiveness should detail the content and method of the intervention delivered, the people (e.g. peer or professional) who delivered it, the training and experience these people had, baseline breastfeeding rates for the study-site population and feeding intention for participants within each comparison group.

Future research should aim to evaluate the effectiveness of the intervention to improve both the initiation and duration of any and/or exclusive breastfeeding at least up to six months to enable appropriate planning and implementation of interventions during pregnancy and the postnatal period.

Further research to evaluate interventions that combine health education or support before the birth with support during the days immediately after the birth should be evaluated and compared with those that offer education alone.

Research to evaluate the impact of adopting and/or implementing the WHO Code on Marketing of Breast-milk Substitutes is urgently needed as well as the use of breastfeeding promotion packs in an environment free of formula-company produced materials.

Further research into early mother-infant contact followed by rooming-in until hospital discharge may be effective at increasing breastfeeding initiation rates among various population groups.

Good quality research to evaluate the effectiveness of breastfeeding promotion and support on breastfeeding rates among maternity and community services who achieve fully accredited Baby Friendly status would further inform policy and practice.

Acknowledgements

Developmental work for this review (development of the conceptual framework for identification and classification of health promotion interventions and the search strategy) was conducted for the purposes of 'A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding', funded by and produced for the NHS Research and Development Health Technology Assessment Programme, UK (Fairbank 2000). Co-authors of this review, not involved in the adaptation and update of this review for the Cochrane Collaboration, were: S O'Meara, Dr AJ Sowden, D Lister-Sharp (NHS Centre for Reviews and Dissemination, University of York, UK) and Dr M Woolridge (Mother and Infant Research Unit, Faculty of Medicine, University of Leeds, UK). An international Advisory Panel of breastfeeding and health promotion experts also provided guidance on the classification of studies and interpretation of findings for the HTA 2000 review. Members of the Advisory Panel were: Rosamund Bryar, Petra Clarke, Leslie Davidson, Elisabeth Helsing, Stuart Logan, Miranda Mugford, Patricia Muirhead, Felicity Savage, Jim Sikorski and Mary Smale.

Analysis 4.1.

Comparison 4 Early mother-infant contact followed by separation for women of all feeding intentions vs standard care, Outcome 1 Initiation of breastfeeding.

Appendices

Appendix 1. Note 1

Unless otherwise stated, the sources of international breastfeeding data are the WHO Global Strategy for Infant and Yound Child Feeding (WHO 2003) or the WHO Global Databank on Breast-Feeding (WHO Data Bank 1996) . The Databank is not comprehensive at this time and is dependent on data collected by individual countries using a variety of methods or indicators, or both.

Appendix 2. Note 2

Figures presented are not standardised for mother's age and age at which she completed full-time education, factors strongly associated with the incidence of breastfeeding. Standardised figures were not available for individual countries. Available data for changes in breastfeeding rates for England and Wales between 2000 and 2005, when standardised for mother's age and education, report a real increase in breastfeeding rates which was not simply due to changes in the sample composition (Bolling 2007).

Appendix 3. Searching information

For the initial version of this review, we also searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2003, Issue 1) and the following databases from inception to October 2002: MEDLINE, CINAHL, ERIC, Applied Social Sciences, PsychLIT, EMBASE, British Nursing Index, BIDS, EPI-centre.

We searched the following in October 2002 for 'grey literature': SIGLE, DHSS Data, and Dissertation Abstracts. Details of the search strategies for all these databases can be obtained from the review authors.

Contributions of authors

F McCormick: second author for final review preparation, third author for data extraction. Administrative support for retrieval and translation of papers.

Professor MJ Renfrew: second author for independent trawling of titles and abstracts and checking of prescreening, data extraction, quality appraisal, analysis and synthesis of findings.

Declarations of interest

None known.

Sources of support

Internal sources

Mother and Infant Research Unit, University of Leeds, UK.

External sources

Canadian Cochrane Child Health Field Bursary Award, Canada.

York Centre for Reviews and Dissemination, UK.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Brent 1995

Methods

Randomisation by permuted block.

Analysis was by intention to treat.

Participants

108 English speaking, nulliparous, pregnant women attending a prenatal clinic, regardless of infant feeding preference were recruited into study. Participants stratified by age into 3 groups (less than 20, 20-29, or at least 30 years).

Interventions

Experimental group: (N = 51). Bf education and support provided throughout the prenatal and postpartum periods and into the first year of the child's life. Education consisted of 2-4 individual 10-15 minute sessions with a lactation consultant discussing the benefits and practice of bf. Content of sessions was based on the women's needs and interests. After delivery, mothers were followed up with daily inpatient rounds by the lactation consultant. Further follow up consisted of a telephone call 48 hours after discharge, a visit to the lactation clinic at 1 week and lactation consultation present at each health supervision visit until weaning or when the infant was 1 year of age, whichever came first. Professional education was directed at nursing and medical staff who interacted with the bf dyad.

Incidence of breastfeeding in hospital. Incidence of breastfeeding at 2 weeks. Incidence of breastfeeding at 2 months. Incidence of breastfeeding at 6 months. Median duration of breastfeeding. Subgroup analysis for women who indicated at the first prenatal visit that they planned to formula feed or were undecided.

Notes

To determine if a comprehensive breastfeeding promotion programme increased the incidence and duration of breastfeeding in a low-income population.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

Unclear whether allocation concealment was adequate.

Blinding? Women and staff

High risk

Inadequate due to non-blinded study.

Blinding? Outcome assessors

High risk

Outcome assessors were not blinded to group allocations.

Incomplete outcome data addressed? All outcomes

Low risk

Adequate, breastfeeding initiation reported for all 108 women in the study.

Caulfield 1998

Methods

Method of allocation of the four clinics: 4 slips of paper labelled with 1 of 4 clinics randomly selected from pot for centralised allocation to a pre-ordered list of comparison groups.

Analysis was not by intention to treat.

Participants

4 clinics administered through the Johns Hopkins University WIC program, that had similar rates for ethnicity (90.4-96.1% African-American) and breastfeeding rates at 1 month (2.0-5.9% in 1991). Women were recruited between April 1992 and January 1994 as they registered for prenatal care at the 4 clinics. 674 women were eligible. 242 had complete data (36%) and only these were included in the results. Differences were noted by clinic in parity, education and employment status before and during pregnancy of the included women.

Interventions

2 x 2 factorial design. Control (N = 57). Routine WIC services and nutrition education. Video intervention (N = 64). Breastfeeding motivational video, based on Best Start video, consisted of 8 trigger vignettes 2-5 mins in length, about benefits of and major benefits to breastfeeding, played continuously in the waiting area without staff supervision. Discussion with service provider following video was encouraged. Posters displayed in clinic areas and relevant sites.

Peer counselling intervention (N = 55). Women interested in breastfeeding received personalised information and support on breastfeeding issues of concern specific to each participant. Women received counselling 3 times during pregnancy. WIC counsellors were former WIC clients, had successfully breastfed and completed 5-week training program.

Video and peer counsellor (N = 66). All the components described above.

Outcomes

Breastfeeding initiation. Breastfeeding initiation by infant feeding intention at enrolment. Breastfeeding at 7-10 days for those who initiated.

Notes

Not included in the meta-analysis on statistician's advice, because with only 1 clinic in each group, it is not possible to calculate the standard error of difference.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

Adequate.

Blinding? Women and staff

Unclear risk

Partially adequate. Randomisation at clinic level minimised crossover and contamination between groups compared to randomisation at level of individual. Unlikely that providers of intervention were blind.

Incomplete outcome data addressed? All outcomes

Unclear risk

Partially adequate.

Chapman 2004

Methods

Recruiter not the same as peer counsellors. Computerised random allocation of weekly cases: appears to be on-site but not stated. Data entry of cases likely to be Research Assistant who recruited but not likely to know how case would be allocated as SPSS random selection.

Analysis was by intention to treat.

Participants

Pregnant women attending Hartford Hospital, Connecticut, USA, on 1 of 3 days a week when recruitment conducted between July 2000 and August 2002. Inclusion (prenatal) over 18 years old, considering breastfeeding, low income. Inclusion (postpartum) healthy full-term singleton infant, no maternal history of HIV. Exclusion: infants admitted to Special Care.

Interventions

Control group (N = 75). Routine prenatal breastfeeding education consisted of individualised breastfeeding information offered in response to women's questions, and written breastfeeding materials from the prenatal clinic. Routine perinatal breastfeeding education included hands-on assistance and education from maternity ward nurses, written breastfeeding materials and access to an IBCLC for breastfeeding problems.

Partially adequate. Data on peer counsellor contact collected at end of each interview.

Incomplete outcome data addressed? All outcomes

Unclear risk

Not applicable for initiation data as no withdrawals reported.

Partially adequate for duration data as reasons for withdrawal not reported.

Coombs 1998

Methods

Allocation method was an opaque container filled with 100 tags (50 - experimental group; 50 - control group). Following greater selection of women to the control group, a statistician calculated the number of C tags to be removed to bias further selection in favour of I tag until groups were balanced.

Analysis was not by intention to treat.

Participants

200 pregnant women, age 18 years or more, literate, no medical conditions likely to make bf difficult, willing to consider using the manual and to undertake interview about bf.

Those who agreed to participate after the interview differed significantly from those who declined in terms of parity, bf knowledge, attitudes, confidence and intention to bf.

Interventions

Experimental group (N = 104). Received the self-help manual 7 weeks before delivery during standard prenatal breastfeeding counselling from nutritionist. The manual was modelled on successful self-help smoking cessation interventions to reduce cigarette smoking among low-income pregnant women using cognitive behavioural theory. Received a total of 2 prenatal interviews and 2 postnatal interviews.

Control group (N = 96). Standard prenatal breastfeeding counselling from nutritionist. No manual. Received a total of 2 prenatal interviews and 2 postnatal interviews.

Inadequate, 23/104 lost from the intervention group and 26/96 from the control group (24.5% overall).

Forster 2004

Methods

A computerised system of biased urn randomisation was accessed by telephone by the research midwife after written consent was obtained.

Analysis undertaken by authors for this review was by intention to treat based on data reported by study authors.

Participants

Women booking for antenatal care at the Royal Women's Hosptial in Melbourne, Australia, between May 1999 and August 2001. The hospital had been an accredited Baby Friendly hospital since 1995. Inclusion: booking as public patients, having a first child, 16-24 weeks' pregnant at recruitment, able to speak and write in English Exclusion: physical problems that prevented breastfeeding, chose birth centre or private obstetric care.

Interventions

Control group (N = 327). Received BFHI accredited standard care. Practical skills intervention (N = 327). In addition to BFHI accredited standard care, received the offer of a single session of 1.5 hours focusing on practical breastfeeding skills. 'Latching on' was explained and demonstrated using dolls and knitted 'breasts'. Breastfeeding complications and management were discussed. Partners were not present.

Attitudes intervention (N = 327). In addition to BFHI accredited standard care, received the offer of 2 1-hour sessions focusing on changing attitudes to breastfeeding. Partners/significant others were encouraged to attend. The first class included information about the advantages of breastfeeding and explored participants' views of breastfeeding and their perceptions of the attitudes of others. Between classes participants were encouraged to interview their own and their partner's mother. The second class included a group discussion based on these interviews, and discussion of resources for breastfeeding women. Women were encouraged to write a breastfeeding plan.

Authors concluded that in settings where breastfeeding initiation is high, neither of the interventions could be recommended as effective. Results not included in the meta-analysis because we considered the control group, BFHI standard care, had received an intervention that meant we could not compare this control group with the control groups of other studies in the review.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

Adequate.

Blinding? Women and staff

High risk

Neither participants nor providers could be blinded because of the nature of the intervention.

Blinding? Outcome assessors

Unclear risk

Unclear whether outcome assessors were blinded to group allocation.

Incomplete outcome data addressed? All outcomes

Low risk

Adequate.

Hill 1987

Methods

Table of random numbers was used to allocate women of different parity to intervention or control groups.

Analysis was by intention to treat.

Participants

64 women intending to give birth at the study hospital and keep their infant, and who gave birth to a healthy infant, and had a telephone or agreed to return the Telephone Interview Survey by post.

95% of the total sample were white women.

Interventions

Experimental group (N = 31). Attended a 40 minute lecture including 5-10 minutes for questions and answers; received a pamphlet with information that reinforced lecture content.

Control group (N = 33). Routine breastfeeding classes to all women attending antenatal clinic with no lecture, discussion, pamphlet or post-test.

Outcomes

Bf knowledge scores. Bf outcomes: no bf, any bf, bf less than 6 weeks, bf more than 6 weeks.

Notes

To determine the effects of a breastfeeding education programme among low-income pregnant women in Chicago.

Risk of bias

Bias

Authors' judgement

Support for judgement

Blinding? Women and staff

High risk

Inadequate. Participants were not excluded from any breastfeeding classes offered by the staff at the antepartum unit regardless of group allocation.

Blinding? Outcome assessors

Unclear risk

Unclear if outcome assessors were blind to group allocations.

Incomplete outcome data addressed? All outcomes

Low risk

Adequate. Breastfeeding initiation reported for all 64 participants.

Howard 2000

Methods

Randomisation using computer-generated random number lists. Potential participants were identified by regularly reviewing first prenatal appointments scheduled at each of the 6 clinical sites. Randomly sized blocks of pregnant women were stratified further by obstetric practice before assigning to study group. 56% of the intervention (research pack) group reported prenatal receipt of formula company promotion items from sources other than their obstetric provider.

Authors stated that attrition from the study did not vary significantly by study group. Of the 547 women randomised, breastfeeding initiation data were not reported for 103 (18.9%).

Analysis undertaken by authors for this review was by intention to treat based on data reported by study authors.

Participants

547 pregnant women attending prenatal visits at any one of 6 obstetric outpatient settings in Rochester, New York.

Participants were largely white (94.4%) and privately insured (96.8%) and most had plans to return to work within 6 months (60%).

Interventions

Experimental group (N = 270). At the first prenatal visit, participants received a research pack containing a generic diaper bag, non-commercial educational materials on pregnancy, infant feeding and infant growth and development, a coupon redeemable for $5 worth of infant items at a local store, and a package of electrical socket outlet covers.

Control group (N = 277). At the first prenatal visit, participants received a commercial pack containing a formula company diaper bag, formula company produced educational materials on pregnancy, infant feeding and infant growth and development, a can of powdered formula, a business reply card to join a 'baby club' redeemable for a case of infant formula, and several infant formula discount coupons.

Outcomes

Any bf at delivery. Mean duration (days) of any bf. Cessation of breastfeeding during hospital stay. Cessation of breastfeeding in relation to breastfeeding goals. Risks for cessation of breastfeeding at 2 weeks.

Notes

To compare the effect of formula company-produced materials about infant feeding, to bf promotion materials without formula advertising, on breastfeeding initiation and duration.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

Unclear if allocation concealment was adequate.

Blinding? Women and staff

Low risk

Adequate due to blinding of both participants and providers.

Blinding? Outcome assessors

Low risk

Adequate. Outcome assessors were blind to group allocations

Incomplete outcome data addressed? All outcomes

Unclear risk

Partially adequate. Reasons for withdrawals in the prenatal (intervention) phase of the study were not reported by group.

Lindenberg 1990

Methods

Randomisation using a table of random numbers for the first 3 months. In the fourth month, a third group were assigned consecutively (due to ethical and organisational limitations) to a second intervention group. Results from this group have been excluded from this study due to the lack of randomisation for allocation.

Analysis was not by intention to treat.

Participants

259 women experiencing a normal, vaginal delivery with no complications and living in poor urban areas of Managua, Nicaragua.

Interventions

Experimental group (N = 136). First 3 months of study: 45 minutes of mother-infant contact immediately after birth with standardised (uniform) breastfeeding promotion followed by complete separation until discharge. Standardised breastfeeding promotion consisted of a series of specific breastfeeding promotional messages.

Control group (N = 123). First 3 months of study: complete separation throughout hospitalisation with usual (ad hoc) breastfeeding promotion. Ad hoc breastfeeding promotion consisted of the routine infant feeding information a mother might receive which, given the large volume of deliveries and short hospital stay, was usually very scant to non-existent.

Outcomes

Any bf at 1 week. Exclusive bf at 1 week. Any bf at 4 months. Exclusive bf at 4 months.

Notes

To examine the effects of early postpartum mother-infant contact, followed by separation until discharge, on the incidence and continuation of breastfeeding.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

Unclear whether allocation concealment was adequate.

Blinding? Women and staff

Unclear risk

Unclear whether blinding of participants and providers for delivery of intervention and standardised care was adequate.

Blinding? Outcome assessors

Low risk

Outcome assessors were blinded to hypothesis regarding breastfeeding and early mother-infant contact.

Incomplete outcome data addressed? All outcomes

Low risk

Adequate. Breastfeeding initiation reported for all participants.

Ryser 2004

Methods

Random assignment by participants selecting a sealed envelope (not sequentially numbered, opacity not specified) to determine assignment to intervention or control group.

Analysis was by intention to treat.

Participants

54 English speaking pregnant women of 18 years or more, literate, eligible for Medicaid, access to telephone and stated feeding intention of 'bottle (formula) feed' or 'undecided'.

Experimental group (N = 26). Received the Best Start Program (Bryant 1990), presented as a breastfeeding promotion campaign that aims to allow health professionals to examine women's misconceptions and educate them about their specific concerns. It has been marketed since 1992 and its materials have been used by various programs, including the SNPWIC Program. In this study, the researcher used the 'Best Start' videotapes, training manuals and handouts to implement the educational program during 4 prenatal visits (2 more than control group as visits also included data collection phase).

Control group (N = 28). No exposure to Best Start Program. No details of routine breastfeeding promotion activities at the physician's office were provided.

Outcomes

Any bf at 1 week postpartum. Attitudes to breastfeeding. Social and professional support.

Notes

To evaluate the effect of the 'Best Start' program on breastfeeding attitudes, intention and initiation in low-income women.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

Unclear whether allocation concealment was adequate.

Blinding? Women and staff

High risk

Inadequte due to lack of blinding of researcher and of participants.

Blinding? Outcome assessors

High risk

Inadequate. Outcome assessors were not blinded to group allocations or study hypotheses.

Serwint 1996

Random number table with blocks of 10 to assign participants. Allocation of women to a paediatrician was not completely random as based on paediatrician availability according to mother's due date.

Analysis undertaken by authors for this review was by intention to treat based on data reported by study authors.

Participants

156 nulliparous women, > 18 years, between 8 and 28 weeks' gestation, who had not yet selected a paediatrician or wanted their infant to receive paediatric care at the hospital-based paediatric clinic.

Both experimental and control groups comprised 91% of African- American women.

Interventions

Experimental group (N = 81). In addition to routine care, received a scheduled prenatal visit between 32 and 36 weeks' gestation at a hospital-based clinic with the infant's future paediatrician. The clinic was in an urban academic medical centre where mothers received their obstetric care. Prior to visits, paediatricians received training in counselling parents of newborn infants and bf techniques/promotion. During visits, paediatricians recorded data on timing of pregnancy, preparation for the infant, involvement of father, social support and maternal medical history. Parents-to-be were counselled on feeding options, advantages of bf, infant car safety, circumcision and access to paediatric healthcare.

Control group (N = 75). Similar management except no prenatal paediatric visits.

Outcomes

Bf intent before prenatal visit. Bf initiation at birth. Bf at 30 days postpartum. Bf at 60 days postpartum. Mothers who changed their mind in favour of bf after enrolment. Parent-physician relationship.

Notes

To assess the impact of prenatal paediatrician visits on breastfeeding decisions of low-income mothers.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

Inadequate concealment of allocation.

Blinding? Women and staff

Unclear risk

Unclear whether participants were blinded to their assigned intervention although providers do not appear to have been blinded to assigned intervention.

Wolfberg 2004

mins: minutes WIC/ SNPWIC: Supplemental Nutrition Program for Women Infants and Children

SPSS: Statistical Package for the Social Sciences

Methods

Method of randomisation not stated.

Analysis was not by intention to treat.

Participants

Pregnant women attending for prenatal care at Johns Hopkins Hospital for an unknown period between March 2001 and August 2002.

Inclusion: consent of woman and partner. All but 1 of the women who completed the study was receiving public assistance or WIC. Most women and partners were black and had more than high school education.

Interventions

Intervention (27 couples completed and contributed data) One 2-hour class for dads on breastfeeding promotion led by a black father. Nondidactic informal teaching method using discussion, role play, videos and slides to dispel myths about breastfeeding and provide information on benefits and technical aspects of breastfeeding.

Control (30 couples completed and contributed data). One 2-hour class for dads on infant care including car seat use, sleeping positions, fire safety, bath safety. Taught by same facilitator using same informal methods.

Outcomes

Breastfeeding initiation. Breastfeeding at 4, 6 and 8 weeks.

Notes

Data not included in meta-analyses because number randomised to each group not reported.

The randomised controlled trial is not yet published, but is currently being considered for publication by the BMJ (email from Pat Hoddinott, 30 June 08).

Wambach 2006

Methods

Participants

Pregnant adolescents

Interventions

Teens in the two intervention groups attend two prenatal classes specific to their focus between the fourth and ninth month of pregnancy and receive telephone calls from a peer counsellor. Teens in a usual care group receive no interventions beyond their standard prenatal care and education. After giving birth and still in the hospital, teens in the intervention groups receive a peer counsellor phone call and visit. Breastfeeding teens in the experimental group also receive a breastfeeding counsellor visit. After hospital discharge, breastfeeding teens from both intervention groups continue to receive peer counsellor telephone support and, in the experimental condition, breastfeeding counsellor phone calls for four weeks. Breastfeeding teens from all three groups complete short telephone interviews until six months after birth or until they stop breastfeeding.

Outcomes

Primary outcome is breastfeeding initiation at hospital discharge.

Notes

30 June 08: Abstract has been updated on the website to indicate study is complete, and Karen Wambach's entry on her University web page states it was completed in late 2007. F McCormick emailed K Wambach to ask about publications.

Forster D, McLachlan H, Lumley J, Beanland C, Waldenstrom U, Harris H, et al. ABFAB. Attachment to the breast and family attitudes to breastfeeding. The effect of breastfeeding education in the middle of pregnancy on the initiation and duration of breastfeeding: a randomised controlled trial. BMC Pregnancy and Childbirth2003;3:5.

Lindenberg 1990 {published data only}

Lindenberg CS, Artola RC, Jimenez V. The effect of early post-partum mother-infant contact and breast-feeding promotion on the incidence and continuation of breast-feeding. International Journal of Nursing Studies1990;27(3):179-86.

Cattaneo 2001 {published data only}

Chapman 1986 {published data only}

Chapman MG, Jones M, Spring JE, de Swiet M, Chamberlain GV. The use of a birthroom: a randomized controlled trial comparing delivery with that in the labour ward. British Journal of Obstetrics and Gynaecology1986;98:182-7.

Feldman 1987 {published data only}

Froozani 1999 {published data only}

Froozani MD, Permehzadeh K, Motlagh AR, Golestan B. Effect of breastfeeding education on the feeding pattern and health of infants in their first 4 months in the Islamic Republic of Iran. Bulletin of the World Health Organization1999;77(5):381-5.

Langer 1996 {published data only}

Langer A, Farnot U, Garcia C, Barros F, Victora C, Belizan JM, et al. The Latin American trial of psychosocial support during pregnancy: effects on mother's wellbeing and satisfaction. The Latin American Network for Perinatal and Reproductive Research (LANPER). Social Science and Medicine1996;42(11):1589-97.

Langer 1998 {published data only}

Langer A, Campero L, Garcia C, Reynoso S. Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers' wellbeing in a Mexican public hospital: a randomised clinical trial. British Journal of Obstetrics and Gynaecology1998;105(10):1056-63.

Martens 2001 {published data only}

Martens PJ. The effect of breastfeeding education on adolescent beliefs and attitudes: a randomized school intervention in the Canadian Ojibwa community of Sagkeeng. Journal of Human Lactation2001;17(3):245-55.

Pobocik 2000 {published data only}

Pobocik RS, Benavente JC, Schwab AC, Boudreau N, Morris CH, Houston MS. Effect of a breastfeeding education and support program on breastfeeding initiation and duration in a culturally diverse group of adolescents. Journal of Nutrition Education2000;32(3):139-45.

Layde 1989

Layde PM, Webster LA, Baughman AL, Wingo PA, Rubin GL, Ory HW, et al. The independent associations of parity, age at first full term pregnancy and duration of breastfeeding with the risk of breast cancer. Journal of Clinical Epidemiology1989;42:963-73.